Provider Demographics
NPI: | 1659034197 |
---|---|
Name: | SEA STARS PEDIATRIC THERAPY, LLC |
Entity Type: | Organization |
Organization Name: | SEA STARS PEDIATRIC THERAPY, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OCCUPATIONAL THERAPIST |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | MARIAM |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | CHINN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MS, OTR/L |
Authorized Official - Phone: | 804-477-4276 |
Mailing Address - Street 1: | 1047 WAYFARER LN |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLESTON |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29412-8424 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 804-477-4276 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1047 WAYFARER LN |
Practice Address - Street 2: | |
Practice Address - City: | CHARLESTON |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29412-8424 |
Practice Address - Country: | US |
Practice Address - Phone: | 804-477-4276 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2021-10-21 |
Last Update Date: | 2021-10-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Single Specialty |